Cognitive Behavioral Treatment of Generalized Anxiety Disorder The original version of these slides was provided by Michael W. Otto, Ph.D. with support from NIMH Excellence in Training Award at the Center for Anxiety and Related Disorders at Boston University (R25 MH08478)

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Slide Set Outline Treatment outcome findings –Perspectives across meta analyses Treatment models –Similarities (over differences) Elements of treatment –What is accomplished in session Future directions

Generalized Anxiety Disorder: Diagnostic Considerations Pervasive worry and chronic arousal Residual category of panic disorder in DSM-III Spheres of worry in DSM-III-R and chronic arousal Excessive and uncontrollable worry and 3 of 6 symptoms in DSM-IV –restless, keyed up, on edge –easily fatigued –difficulties concentrating –irritability –muscle tension –sleep disturbance

Core Patterns in GAD Uncontrollable worry Future orientation Negative cognitive biases Somatic arousal Role and task inefficiency Interpersonal aversiveness (unbalanced relationships)

GAD: Core Treatment Elements Information Applied Relaxation Cognitive Restructuring (probability estimates, coping estimates) Cue-Controlled Worry (worry times + problem solving) Worry Exposure (including existential topics) Mindfulness

Meta-Analyses: 5 Perspectives All Randomized Trials (pre-post) –Norton & Price, 2007 Placebo-Controlled Trials (controlled effect size) –Hofmann & Smits, 2008 Elements of Treatment (controlled effect size) –Gould et al., 2004 Differential Efficacy (pre-post) –Siev & Chambless, 2007 –Gould et al., 2004 Effectiveness Trials (pre-post) –Stewart & Chambless, 2009

Meta-Analysis of Randomized Anxiety Trials of CBT (within ES) Norton & Price, 2007, JNMD Effect Size (d)

Hofmann & Smits (2008) Meta-Analysis Meta-analysis of well-controlled trials of CBT for anxiety Inclusion criteria: –Random assignment to either CBT or placebo –The psychological placebo had to involve interventions to control for nonspecific factors (e.g., regular contact with a therapist, reasonable rationale for the intervention, discussions of the psychological problem)

Meta-Analysis of Controlled Trials of CBT (Between ES) Hofmann & Smits, 2008, J Clin Psychiatry Effect Size (g)

Gould et al., 2004 Meta-Analysis 16 studies Mean drop-out rate 11.4% Mean 10.1 hours of treatment No difference in outcome for studies allowing stabilized medications Maintenance of treatment gains across 6 months

Meta-Analysis of CBT – Gould et al., 2004 Between Groups Effect Size (d)

Specificity of Treatment (Siev & Chambless, 2007, JCCP) GAD CT = RT Panic Disorder CT* > RT Cognitive Therapy (CT) includes interoceptive exposure Relaxation Therapy (RT)

Meta-Analyses of Effectiveness Studies (Within ES) (Stewart & Chambless, 2009, JCCP) Effect Size (d)

Comorbidity and Treatment (Newman et al., 2010) 76 treatment seeking adults with GAD 14 sessions of treatment 60.5% had comorbidity Comorbid diagnosis linked to greater GAD severity at pretreatment Greater change with treatment for those with comorbid depression, social anxiety disorder, specific phobia Normal maintenance of treatment gains Benefits to social anxiety disorder and specific phobia were maintained over 2 years, whereas benefits to depression were not

CBT Models of GAD (Behar et al., 2009, J Anx Dis) Avoidance Model of Worry and GAD –(Borkovec, 1994; Borkovec et al., 2004) Intolerance of Uncertainty Model –(Dugas et al., 1995; Freeston et al., 1994) Metacognitive Model –(Wells, 1995) Emotion Dysregulation Model –(Mennin et al., 2002) Acceptance-Based Model of Generalized Anxiety Disorder –(Roemer & Orsillo, 2002, 2005)

Wells (1999) “Worry is a chain of catastrophising thoughts that are predominantly verbal. It consists of the contemplation of potentially dangerous situations and of personal coping strategies. It is intrusive and controllable although it is often experienced as uncontrollable. Worrying is associated with a motivation to prevent or avoid potential danger. Worry itself may be viewed as a coping strategy but can become the focus of …concern.”

Two Types of Worry (Dugas & Ladouceur, 2000) Situations amenable to problem solving –Training in step-by-step problem solving Situations that are not amenable to problem solving (hypothetical problems that never happen) –Worry times –Worry exposure

Avoidance Function of Worry Worry, a verbal process, inhibits vivid mental imagery and associated anxiety (Borkovec) Evidence that it does attenuate: –somatic arousal at rest ( Hoehn-Saric & McLeod, 1988; Hoehn- Saric, McLeod, & Zimmerli, 1989; Lyonfields, Borkovec, & Thayer, 1995; Thayer, Friedman, &Borkovec, 1996 ) –upon subsequent exposure to threat-related material ( Borkovec & Hu, 1990; Peasley-Miklus & Vrana, 2000 )

Worry and Conditioning Non-clinical levels of worry are linked to greater conditionability –(Otto et al., 2008; Hermans et al., 2009) Potential role for rumination in keeping CS – UCS link alive

Borkovec Encourage a present focus vs. future (past) –Leave patients expectancy free

Positive Beliefs About Worries Worrying: Is useful for finding solutions to problems Is motivating – helps get things done Is protective from negative emotions Can prevent negative outcomes Is a positive personality trait (Francis & Dugas, 2004)

Negative Problem Orientation Problems are threat to well-being Doubt about problem-solving ability Pessimism about problem solving outcome Negative problem orientation is more specific to worry than depression in student samples, and is differentiated from neuroticism (Robichaud & Dugas, 2005, BRAT)

Intolerance of Uncertainty Motivates unnecessary worry-based planning –“What if X happens, could I cope by…”

All current models tend to underscore avoidance of internal experiences Cognitive avoidance Emotional avoidance Intolerance of uncertainty Negative cognitive reactions to emotions Combined With –Positive beliefs about worry –While being concerned about effects of worry

Treatment Elements Borkovec 1.Awareness and self-monitoring 2.Relaxation 3.Cognitive therapy 4.Imagery rehearsal of coping strategies (see Borkovec, 2006 for review)

Treatment Elements Wells 1.Case formulation 2.Socialization to treatment 3.Modifying negative beliefs about the uncontrollability of worry 4.Modifying beliefs about the danger of worry 5.Modifying positive beliefs about worry (Wells, 1999)

Treatment Elements Dugas et al. 1.Uncertainty recognition and behavioral exposure 2.Re-evaluation of the usefulness of worry 3.Problem-solving training 4.Imaginal exposure (Dugas et al., 2003)

Relaxation Strategies Progressive Relaxation (PR; e.g., Bernstein & Borkovec, 1973) Applied Relaxation (AR;O¨ st, 1987). –AR does include exposure elements

Mechanism of Relaxation Training (Ost, 1992) Reduces general tension and anxiety (and link stressor/panic) Enhances awareness about how anxiety works, de- mystifying and diminishing its impact Enhances self-efficacy : individuals feel equipped to cope with anxiety

Relaxation Training Feel the difference between tension and relaxation Tense 7 seconds, relax 15 Specific muscle groups to learn the procedure Group them as skill increases Use 10-second relaxation cue

The “Words” of Worry Non-specific and hard to dispute –It will be horrible –It will be a disaster Downward Arrow Techniques to clarify worries and put them in a form appropriate for cognitive- restructuring

Cognitive Restructuring Self monitoring Logical analysis Probability overestimations Overestimations of the degree of catastrophe –Ability to cope

Relapse Prevention in Depression - Metacognitive Awareness Classic CT and mindfulness-based CT both enhance metacognitive awareness Level of metacognitive awareness is linked to relapse Changing the relationship people have to their thoughts, rather than changing beliefs, may be important for preventing relapse (Teasdale et al., 2002)

Mindfulness – Curious attention to the present moment, in an open, nonjudgmental, and accepting manner –(Bishop et al., 2004; Germer, 2005; Kabat-Zinn, 1994)

Why Mindfulness? Hayes and Feldman, 2004 –Mindfulness training may enhance emotional regulation by addressing the patterns of over-engagement (e.g., rumination) and under-engagement (avoidance) that characterizes the disorder. –Target is a healthy level of engagement that “allows clarity and functional use of emotional responses” Roemer et al, 2009 –Non-clinical symptoms and clinical GAD status linked to lower mindfulness

Worry Time Save up the worry (cue specificity) End of the day worry time In office (non-fun) setting 45 min – with writing 10 min – relaxation skills Go have fun

GAD: Worry Exposure Metaphor: Like watching a scary movie over and over – decreased arousal and changed meaning of the worry Apply exposure plus response prevention (including the use of tape loops) The goal is elimination of the worry response via repeated exposure to core fears This technique should also be coupled with the prescription to worry through one topic and not switch among “spheres of worry”

GAD: Training in Normal Thinking Teach “normal thinking” as alternative behavior. What does one think about when not preoccupied with worry? Mindfulness of thinking states that are different from worry (e.g. daydreaming, experiencing, planning, enjoying) Sensory awareness training “Staying in the moment” Use of “worry times” Limited effects of exposure on valence/preference

Attention ModificationTraining - GAD 29 treatment seeking patients Random assignment (train away vs. no train threat words) 8 sessions over 4 weeks Goal: –Change attentional bias –Change GAD symptoms Succeeded with both –Between group effect size of.80 –Least efficacy on worry (Amir et al., 2009, J Abn Psych)

Attention Modification Training - GAD Randomized clinical trial GAD (N = 29) Stimuli: threatening or neutral words 50% of those in the active attention modification program were classified as responders (no longer meeting DSM diagnosis for GAD) vs. 13% in the control condition (Amir et al., 2009)

New Directions Attentional training Mindfulness/emotional tolerance training Interoceptive exposure Integrative treatment

GAD Interpersonal Roles Polarizing the relationship: the worry partner Improving couple’s problem-solving

Conclusions Nice convergence of strategies in the field Need to convincingly beat relaxation training as a first step in care Need to confirm resilience of treatment to depression (but emergent finding across anxiety disorders) Room for improvement – to achieve high end-state functioning